Senior Friendly Hospitals: A Provincial Strategy & Let s MOVE ON Geriatrics Refresher Day Ottawa March 21, 2012

Transcription

1 Senior Friendly Hospitals: A Provincial Strategy & Let s MOVE ON Geriatrics Refresher Day Ottawa March 21, 2012 Barbara Liu, MD, FRCPC Executive Director 1

2 Outline The challenge for hospitals A SFH framework The provincial senior friendly hospital strategy Results to date Next steps Alignment 2

3 RGP Senior Friendly Hospital Framework Processes of Care Emotional & Behavioural Environment Ethics in Clinical Care & Research Organizational Support Physical Environment What we do How Who Why Where 3

4 Senior Friendly Hospital Provincial Strategy Objective Identify current state Plan Hospital self Assessment LHIN level roll up Provincial roll up Objective Close the gap Plan Implement hospital improvement plans Develop key enablers Objective Monitor and sustain hospital and system improvements Future State Prevent functional decline Improve patient experience Enable hospital staff Improve equity 4

5 Senior Friendly Hospital Care in the TC LHIN 5

6 Senior Friendly Hospital Care in Ontario Senior Friendly Hospital self assessments completed by 155 hospitals in Ontario 6 RGPs of Ontario worked with 13 LHINs to generate regional SFH summary reports Coordination by TCLHIN and RGP of Toronto 6

7 Provincial Summary Report Describes existing state of SFH care in Ontario Identifies promising practices Recommends priority areas for action 7

8 Organizational Support Hospital Leadership 56% of hospitals designated a senior executive to lead SFH 39% had SFH goals in strategic plan 30% had explicit commitment at level of board of directors Supporting Human Resources Development 55% had geriatrics content in orientation or education for staff frailty focused education to all staff developing geriatrics champions HR policies that encourage skills development in geriatrics Service Planning Structures solicit input from community and health system partners 8

9 Processes of Care Clinical Protocols/Monitoring most common falls, pressure ulcers, restraint use, pain management least common management of behaviours, sleep, functional decline, hydration/nutrition functional decline an emerging priority Interprofessional Practice in the Hospital geriatric assessment teams, leveraging volunteers Inter-organizational Collaboration for Transitions in Care post D/C follow-up care partnerships for transitional care 9

10 Emotional and Behavioural Environment Patient Centred Care Designed with Seniors in Mind 28% of hospitals age specific measures in satisfaction or quality improvement initiatives Staff for way finding, personal menu assistance Supporting Communication and Patient Involvement in Care hearing amplifiers, translation services team rounds at the bedside Early goal setting discussions discharge planning information packages 10

11 Ethics in Clinical Care and Research Access to a Clinical Ethicist for Complex Situations 83% of hospitals have access to a bioethicist regular learning opportunities (case studies, lunch and learns) Procedures for Capacity and Consent Issues internal processes involving appropriate clinical staff consultation with external bodies Procedures for Advance Directives 78% of hospitals have formal policies/procedures, but many are limited in scope to resuscitation orders resources provided to patients, families and care team to guide advance care directives 11

12 Physical Environment 34% of hospitals have performed SFH audits to prioritize improvements to physical spaces overall reliance on AODA and building code standards in physical planning involvement of clinical staff and older adults in physical environment planning to inform design team 12

13 Provincial SFH Action Priorities Functional Decline Implement interprofessional early mobilization protocols across hospital departments to optimize physical function Delirium Implement interprofessional delirium screening, prevention, and management protocols across hospital departments to optimize cognitive function Transitions In Care Implement practices and developing partnerships that promote interorganizational collaboration with community and post-acute services 13

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15 Senior Friendly Hospital Provincial Strategy Objective Identify current state Plan Hospital self Assessment LHIN level roll up Provincial roll up Objective Close the gap Plan Implement hospital improvement plans Develop key enablers Objective Monitor and sustain hospital and system improvements Future State Prevent functional decline Improve patient experience Enable hospital staff Improve equity 15

16 Toolkit Working Group Dr. Barbara Liu (Co Chair), RGP Toronto Dr. Gary Naglie (Co Chair), Baycrest Centre Ken Wong, RGP Toronto Dr. John Puxty, RGP SE ON David Jewell, RGP Central ON Anne Stephens, TC CCAC Sharlene Kuzik, NW LHIN Linette Perry, Stevenson Memorial Hospital Maria Boyes, Cambridge Memorial Hospital Susan Franchi, St. Joseph s Care Group Karyn Popovich, North York General Hospital Dr. Monidipa Dasgupta, St Joseph s Health Care (London) Bruce Viella, NE LHIN Susan Bisaillon, Trillium Health Centre Emily Christoffersen, Hamilton Health Sciences 16

17 Toolkit Development Process Literature review Tools shortlisted Voting on Feasibility Interprofessional usability Need for additional resources/training contributes to enhanced care 499 responses on 34 tools from 25 people Structure Description, definition, rationale Recommendations from provincial summary report Screening and detection tools Prevention and management guidelines, review articles, other Knowledge exchange portal 17

18 SFH Toolkit Home Page Located Located within within Senior Senior Friendly Friendly Hospitals Hospitals tab tab access access to to other other tabs tabs provides provides a a handy handy link link to to related related RGP RGP resources resources direct direct navigation navigation also also via via

19 Tools Clicking on the tool link opens a summary page containing practical information on use of the tool, instructions and sourcing information

20 Evidence based content Where Where applicable, applicable, the the evidence evidence from from the the literature literature is is organized organized by by SFH SFH Framework Framework domain domain tabs, tabs, reinforcing reinforcing organization wide organization wide approaches approaches SCROLL

21 Provincial SFH Action Priorities Functional Decline Implement interprofessional early mobilization protocols across hospital departments to optimize physical function Delirium Implement interprofessional delirium screening, prevention, and management protocols across hospital departments to optimize cognitive function Transitions In Care Implement practices and developing partnerships that promote interorganizational collaboration with community and post-acute services 21

22 Mobilization of Vulnerable Elders Co PI: B Liu, S Straus Sunnybrook HSC St. Michael s Hospital Baycrest Mt. Sinai Hospital 22

23 Knowledge-to-Action Cycle Select, Tailor, Implement Interventions Assess Barriers to Knowledge Use Adapt Knowledge to Local Context Monitor Knowledge Use KNOWLEDGE CREATION Knowledge Inquiry Synthesis Products/ Tools Identify Problem Tailoring Knowledge Evaluate Outcomes Sustain Knowledge Use Identify, Review, Select Knowledge Graham et al.,

24 Complications of Immobility Respiratory System Decreased lung volume Pooling of mucous Cilia less effective Decreased oxygen saturation Aspiration Atelectasis Gastrointestinal System Reflux Loss of appetite Decreased peristalsis Constipation Musculoskeletal System Weakness Muscle atrophy Loss of muscle strength by 3-5% Calcium loss from bones Increased risk of falls due to weakness Psychological Anxiety Depression Sensory deprivation Learned helplessness Delirium Circulatory System Loss of plasma volume Loss of orthostatic compensation Increased heart rate Development of DVT Genitourinary System Incomplete bladder emptying Formation of calculi in kidneys and infection

25 ...rest in bed is anatomically, physiologically and psychologically unsound. Look at a patient lying long in bed. What a pathetic picture he makes! The blood clotting in his veins, the lime draining from his bones, the scybala stacking up in his colon, the flesh rotting from his seat, the urine leaking from his distended bladder and the spirit evaporating from his soul.

26 Selected RCT evidence for early mobilization Surgical Dx Many RCTs Pneumonia Stroke Cochrane Review (2009) LOS 5.8 vs. 6.9 days (Mundy Chest 2003;124: ) Barthel Index at 3 months Earlier return to walking 3.5 vs. 7 days P=0.03 (Cumming TB Stroke 2011; 42 :153) Discharge to home, NNT=16 LOS by 1.08 days ( 1.93 to 0.22)

27 Lying 83% of measured hospital stay spent in bed Median time spent standing or walking = 43 minutes or 3% of day Sitting Walking Brown, C et al JAGS 2009;57:

28 Baseline Data % in bed unit 1 % in bed Unit 2

29 Processes of Care Processes of Care Organizational Support Physical Environment Ethics in Clinical Care & Research Emotional & Behavioural Environment Brown, C et al J Hosp Med 2007;2:305 29

30 Fishbone diagram

31 Knowledge-to-Action Cycle Select, Tailor, Implement Interventions Assess Barriers to Knowledge Use Adapt Knowledge to Local Context Monitor Knowledge Use KNOWLEDGE CREATION Knowledge Inquiry Synthesis Products/ Tools Identify Problem Tailoring Knowledge Evaluate Outcomes Sustain Knowledge Use Identify, Review, Select Knowledge Graham et al.,

32 Goals of MOVE ON Mobility assessment within 24 hours of the decision to admit and reassessment daily At least three times a day, progressive, scaled mobilization 32

33 Mobility Assessment Algorithm

34 Simplified Mobility Assessment Algorithm 1. Can they respond to verbal stimuli? 2. Can they roll side to side? 3. Can they sit at edge of bed? 4. Can they straighten one or both legs? 5. Can they stand? 6. Can they transfer to a chair? 7. Can they walk a short distance? Mobility Level C B A

35 A Review of the ABC s of Mobility 35

36 Daily assessment of mobility status Mobilize three times daily Incorporates interprofessional teamwork and attitude awareness training Multipronged tailored education

37 First step is to dangle To Chair

38 Respiratory ICU Intermountain Medical Center Salt Lake City, Utah 38

39 Senior Friendly Hospital Provincial Strategy Objective Identify current state Plan Hospital self Assessment LHIN level roll up Provincial roll up Objective Close the gap Plan Implement hospital improvement plans Develop key enablers Objective Monitor and sustain hospital and system improvements Future State Prevent functional decline Improve patient experience Enable hospital staff Improve equity 39

40 Indicator Working Group Dr. Barbara Liu (Co Chair), RGP Toronto Rhonda Schwartz (Co Chair), Baycrest Centre Ken Wong, RGP Toronto Michelle Rey, Health Quality Ontario Rebecca Comrie, Health Quality Ontario Annette Marcuzzi, Central LHIN Marilee Suter, Central East LHIN Brian Putman, North Simcoe Muskoka LHIN Minnie Ho, ICES Dr. Carrie McAiney, St. Josephs Healthcare Hamilton Dr. John Puxty, RGP SE Ontario Dana Chlemitsky, University Health Network Dr. Sharon Marr, RGP Central Ontario Kim Kohlberger, Halton Healthcare Catherine Cotton, St. Joseph's Health Centre Kelly Milne, RGP Eastern Ontario 40

41 Indicators workplan/timeline 41

42 Patient & Care Team Alignment and momentum Sustain 42

43 The goals of the SFH (win-win-win) Patient / family Minimize risk, improve safety Maximize functional ability, improve outcomes Improve care experience & satisfaction Staff Enabled to deliver best practice Improve satisfaction Hospital Strategic Alignment Improve quality Reduce adverse events & iatrogenic complications Improve capacity for independent living Reduce ALC and readmissions 43

44 National Round Table Meeting on Quality and Safety Standards for Older People in Canadian Hospitals PI: B Liu, B. Parke, A Juby Quebec City, April 19, 2012 Populations standards working group Draft standards for system planning being piloted Receptive to expanding ROPs to include more senior relevant standards. 44

45 Next steps Knowledge exchange and networks LHIN-wide networks and provincial collaborative SFH is a continuous cycle Expanded improvement plans Enhanced toolkit resources LHIN Integrated health services plans MOHLTC Seniors Strategy HQO QIPs 45

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47 Processes of Care Ethics in Clinical Care & Research Processes of Care Emotional & Behavioural Environment Organizational Support Organizational Support Ethics in Clinical Care & Research Physical Environment Emotional & Behavioral Environ ment Physical Environ ment

48 .a focus on geriatrics as the solution, not the problem. J. Bennett,

49 TC LHIN C Orridge V Sakelaris R Cook T Martins G Whitehead S Smit TC LHIN SFH Taskforce J Bennett (Co Chair) B Liu (Co Chair) M Codjoe C Cotton S VanDeVelde Coke P Cripps McMartin L Dess C Levy SFH Toolkit Working Group of Ontario G Naglie, B Liu co chairs, et al. SFH Indicator Working Group of Ontario R Schwartz, B Liu co chairs, et al. TC LHIN SFH indicator Working Group J Bennett (Co Chair) B Liu (Co Chair) C Cotton L Dess C Levy C Millar J O Neill M McCarthy S VanDeVelde Coke K Velji J Walsh SFH LHIN Leads Working Group of A ON Anderson J Girard G Whitson Shea S Isaak S Stewart N Jaffer H Willis T Martins A Marcuzzi B Laundry C Russell C LeClerc P Istvan S Colwell M Auchinleck B Villella K Tasala